Vol. 17 Issue 22
In Children with Autism
A growing body of research suggests that the simultaneous use of vocal and sign training helps children with autism develop functional communication skills.
Vincent Carbone, EdD, BCBA, director of The Carbone Clinic in Valley Cottage, NY, has conducted several studies on the topic including a recently published study that has demonstrated increased vocal production in children with autism who have word retrieval problems (Journal of Speech-Language Pathology and Applied Behavioral Analysis, Sept. 25, 2006).
Dr. Carbone's research has found that the combination of specific signs and requests, or mandinga term for requesting created by the psychologist B.F. Skinnerused in conjunction with a verbal prompt will result in increased vocalizations in some children with autism.
"It appears that alternative forms of communication that involve motor movements correlated with one of the relevant items that are being asked for seems to be an important factor," he told ADVANCE. "That may be why sign languagealthough there are not an enormous amount of datamay be a more likely avenue to produce speech, mainly due to the fact that each sign is correlated to a different movement, and that's what we found in our study."
"The different motor movements may be correlated with the speech sounds and the motor movements of the child may then act as a kinesthetic, and even visual, cue for the word," he said. "It's also been found that it's only when it's done in the context of what's relevant to the child, which is what makes manding important."
Such research in behavioral analysis can have tremendous crossover for the field of speech-language pathology, said Tamara Kasper, MS, CCC-SLP, BCBA, owner and director of The Center for Autism Treatment, Inc., in Cedarburg, WI. Kasper has collaborated on research with Dr. Carbone, who is her mentor.
"In this day of evidence-based practice, we know that behavior analysis, according to multiple sources, is really the only documented effective treatment for children with autism. When we view procedures from the field of speech-language pathology as a behavior analyst, we can really make modifications in our procedures that result in huge changes for our kids."
Dr. Carbone urged speech-language pathologists to look at the common ground between their professional literature and behavioral literature. "Effective practice knows no discipline," he said. "Effective practice occurs across all philosophies and all disciplines as it relates to the development of language."
During his initial evaluation of a child with autism, Dr. Carbone first will assess motor imitation skills and transcribe a substantial amount of the child's vocal production to determine if an alternative form of communication is required. "Basically our criterion is if most of what a child says is unintelligible to an unfamiliar listener outside the context in which it is said, then we would suggest that that child is a candidate for an alternative form of communication," he explained. "Almost always for children with autism, we choose sign language."
Even children with poor motor imitations may benefit from sign language, he noted. "We feel we can be very good about prompting their hands and shaping their signs even in children that don't imitate particularly well."
Sign language also is a practical choice for children with autism, who tend to be fairly active at a young age with interests that tend to be activity-based. "Many of the first requests we get from children are things like jumping, being thrown up in the air, tickling and playing. [It's] really difficult to get a picture system or some selection-based voice output system operating within those contexts," he said.
Jenn Godwin, MEd, BCBA, clinic director for the Early Autism Project, Inc., in Sumter, SC, said children with autism become more aware of the importance of vocalization after a series of reinforcing activities cater to their interests and demands. "We continue just contriving as many opportunities as we can per day to teach them to be able to request or mand for different things, and then talking becomes valuable to them," she explained. "So they learn, 'If I talk I get something; if I sign, I get something.' "
Finding the activities that interest children with autism is often the first challenge to overcome before even introducing manding. "That in itself presents a challenge," acknowledged Kasper. "They're less motivated to communicate because they have fewer things they're interested in asking for."
Before teaching mands, Kasper spends a significant amount of time identifying the child's intereststheir reinforcers. Her next task is to associate herself with those items and their delivery.
"We want them to look at us and think, 'I want to go to Tammi–she knows exactly what I want and exactly what I like,' " she explained. "We are like the conduits through which they're receiving all the things that they enjoy so it gives us that opportunity to prompt them to sign and then to deliver those items."
Godwin has found that outdoor activities often are popular reinforcers with the children she sees at her clinic. She has used activities such as swinging, jumping on a trampoline, and sliding, as well as specific food items and beverages, as reinforcers.
"When I started working with Dr. Carbone and I saw what happened when you started teaching kids from the beginning to request for reinforcing activities, [I saw] how much quicker they learn to communicate and develop vocalization," she said. "Manding or requesting is such a huge component of teaching children to be able to become vocal learners as well as teaching them the value of talking. For parents, being able to have your child communicate is often a primary goal for families I work with."
Once the items and activities of interest are identified, Kasper works to teach individual signs for those items. "We use specific signs, one-on-one signs," she said. "We don't use 'more,' 'help,' 'please,' or 'want.' "
In the first five to eight signs she teaches, she avoids using ones that are too similar in terms of their category such as food items, beverages and physical play. "I wouldn't want to teach 'pretzel' and 'chip' at the same time because they're so similar that it's unlikely that the child is going to learn to discriminate that easily," she explained. "If he accidentally signs 'chip' and he gets a pretzel, he may not show any negative response to that."
Avoiding generalized signs is key to therapy success. "You would never want to teach one sign that got many reinforcers," Dr. Carbone said. "If you do, then that's the only sign you would ever get, and then it's hard to teach additional signs."
Kasper says she is surprised by the number of speech-language pathologists who still use generalized signs in therapy. "Even though it's been in our textbooks since 1980 that we need to know not to teach generic signs to kids with autism and other developmental disabilities, a lot of people are still teaching 'more,' 'me,' and 'want.' "
When she gives workshops on manding and vocalization she works with clinicians and educational teams to model specific signs and prompt the child to produce the sign before delivering the item or activity.
It is important to know when to fade any and all prompts that are given to the child, she stressed.
"Kids with autism have a tendency towards prompt dependency so we have to be very careful in our teaching strategies that we're prompting well, but we're also fading those prompts very strategically so they don't develop dependency on prompts. This can happen if you're not careful in teaching," Kasper said.
In many of the children she works with, she said her first indication of when to fade is feeling the child move their hands underneath hers. "The minute you start to feel that, you want to start prompting less," she said. "They've reached for a cracker, you've modeled the sign 'cracker,' you've physically guided them to make the sign using a full physical prompt. The very next trial, when you bring out the cracker, you might just touch their arms a little bit instead of giving that full physical prompt so you're fading from a full physical to a partial physical."
When a child starts signing on his own she will increase his reward–two crackers instead of one, for example–so the child understands that the less-prompted sign contacts reinforcement.
At her clinic, Godwin works with parents to help them teach children new mands and signs at home. "We set up training to teach the parents how to handle problem behavior and also teach them how to show their child how to request for things, or, how to prompt that request and then fade their prompt so the child can be more independent," she said.
In each trial the therapist should ensure that the child is giving the most independent response possible. Dr. Carbone uses a time delay incorporated into an errorless teaching method. If an instructor presents the child with an object, asks the child to identify it and then names the object, the child will repeat the answer.
"If you didn't provide that prompt at that moment, the child would probably be wrong and you would increase the number of errors and therefore increase the amount of resistance to therapy," he explained.
On the next trial, the instructor will begin immediately to fade the prompt by inserting a two- to three-second delay between their identification question and the child's answer. The process is known as a stimulus control transfer procedure. "You've removed the prompt and now somewhat ensured that the response is appropriate and not occurring just because you said the word first," Dr. Carbone said.
Kasper agreed. "That little time delay makes the difference between someone who is an independent communicator and someone who is dependent on an adult's prompt," she said.
She suggests beginning work on vocalizations with the child when he has at least 10 signs that can be produced independently upon seeing the item. Then, when the child makes a sign for a word such as "chip," Kasper makes the sign and says "chip." She waits one to two seconds between each production and repeats the trial three to five times.
"If the child at any time during those three to five trials signs and uses a vocalization, he immediately gets the chip and he gets it in a greater quantity," she said. "Now that we've established using signs it's upping the ante and saying we want signs and vocalization as your response, and here's how we're going to show you that."
Kasper picks target approximations of the word she wants the child to vocalize during the trials. For a word like "chip," she might look for "dip" as an approximation. If the child has not said "dip" during the trials, she will reward him with a small piece of chip. If the child meets the target approximation, she will give him a greater quantity of chip and additional social praise to serve as a reinforcer.
She has worked with Nancy Kaufman, MA, CCC-SLP, director of The Kaufman's Children Center for Speech, Language, Sensory-Motor, and Social Connections, Inc., and international expert in apraxia, to create a set of treatment materials to promote manding. The K & K Sign and Say Verbal Language Kit consists of cards with a photo of an activity or toy on the front and instructions on how to make the sign for the item and its successive vocal approximations on the back.
"Nancy Kaufman calls them 'word shells' that are based on typical phonological processeshow typical kids might learn to say that word," Kasper explained.
During the table trainingapart from the mandingshe will work with the child on shaping vocalizations using the word shells. "It's amazing how well this works, how quickly kids start developing vocalization. It's very exciting," she said. "We have a good bit of research now to support the sign language plus vocalization training."
For More Information:
Vincent Carbone, EdD, online: www.carboneclinic.com
Jennifer Godwin, online: www.sceap.com
Tamara Kasper, online: www.centerautismtreatment.org
Alyssa Banotai is an Associate Editor for ADVANCE. She can becontacted at email@example.com.
Dealing with Problem Behavior
Children who have difficulty communicating often exhibit problem behavior, particularly children with autism who may struggle with vocalization. The first step to prevent problem behavior during request, or manding, therapy is to understand its origin, said Vincent Carbone, EdD, BCBA, director of The Carbone Clinic in Valley Cottage, NY.
"There's a line of research on functional assessment that has established the fact that problem behavior usually occurs for one or several possible reasons. Most of the [reasons] that are socially related have to do with children engaged in problem behaviors to get certain things or get out of certain things," he explained.
Tamara Kasper, MS, CCC-SLP, BCBA, owner and director of The Center for Autism Treatment, Inc., in Cedarburg, WI, who has conducted research with Dr. Carbone, noted that many of the children with autism she works with initially engage in problem behavior because it is a communication method with proven results. "That's how they've accessed things in the past," she said. "It's quite effective to reach and grab something out of your little sister's hand, or scratch someone and they drop the toy so that you now have it."
Once the cause of the problem behavior is identified, Dr. Carbone works to eliminate it by using a replacement behavior, which usually is signing. Knowing a child's interests, or reinforcers, and meeting those demands by teaching a child to sign for them makes a child more likely to respond to therapy. The therapy room becomes a place where the child knows his needs will be met and the therapist becomes a person who is willing to deliver the desired objects and activities, he explained.
"A large percentage of problem behaviors of children with autism during therapy are motivated by escape or avoidance," he said. "They have learned that teaching sessions are not very interesting, not very fun or not very reinforcing for whatever reason."
Turning therapy into an improving set of conditions reduces problem behavior and heightens the child's openness to learning and eventual vocalization.
"Make the therapy session more fun than anything else they might be doing at the time by manipulating reinforcers and motivation, and then by using a set of teaching practices in which we begin to increase the number of demands, make the number of demands easy, use errorless teaching, and mix and vary the demands," he suggested. "Keep a low number of demands at first, [then] intersperse high rates of mastered skills to low rates of target skills. By doing that, we can keep the session relatively fun and not have to teach the avoidance behavior, and the child wants to be with us." The practice is referred to in professional literature as abolishing the reflexive motivating operation, he explained.
Despite replacement behaviors and enjoyable therapy sessions, problem behavior still may occur, Kasper warned. If a demand is not met on time, such as a delay in opening a bag of chips that the child has requested, the old way of requestingthrough scratching, screaming or yellingmay return. To stop the behavior, she uses a technique developed by Dr. Carbone called the "count and mand"giving the child a signal to indicate disapproval of the behavior. "We say 'no screaming' and we put our hand up and we use our fingers to show the passage of time," she explained.
Using a count of at least five secondsuntil the child is quiet for the full 5 secondsshe will then go back and prompt the original sign and will deliver the item when the child delivers the sign. "What we're trying to teach them is it's not the screaming and then the signing that gets the item," she said. "It has to be the signing all by itself, so we're creating that time delay."
Once the child's signing ability has strengthened, the child will begin to repeat the sign and may use a vocalization when delivery of an item is delayed rather than resorting to problem behavior.
"If we teach him by using that count and mand procedure, he realizes that it takes longer to get what he wants when he does the wrong thing than when he does the right thing," she said.